PERSONAL FINANCIAL STATEMENT
TO: GATEWAYBANK OF CENTRAL FLORIDA as.of:
If statement is joint, please complete the following:
NAME: NAME:
(Individual 1) (Individual 2)
ADDRESS: SOCIAL SECURITY #:
CITY, STATE: ZIP: BIRTH DATE:
SOCIAL SECURITY #: BIRTH DATE: I intend to apply for joint credit
NOTE: IF THERE IS A JOINT PARTY TO THIS FINANCIAL STATEMENT WHO IS EITHER BORROWING OR GUARANTEEING THE CREDIT UNDER CONSIDERATION, THE COLUMNS TITLED "SOLEL Y OWNED -INDIVIDUAL 2" AND "SOLa Y UABLE -INDIVIDUAL 2" MUST BE FILLED OUT.
ASSETS SOLELY OWNED JOINTLY OWNED TOTAL
INDIVIDUAL 1 INDIVIDUAL 2
CASH (INCLUDES CD'S, MONEY MARKETS SCHEDULE 1
GOVERNMENT & READILY MARKETABLE SECURITIES SCHEDULE 2
NON-MARKET ABLE SECURITIES SCHEDULE 3
NOTES AND ACCOUNTS RECEIVABLE
CASH VALUE OF LIFE INSURANCE SCHEDULE 4
PERSONAL RESIDENCE/S) SCHEDULE 5
OTHER REAL ESTATE SCHEDULE 5
PERSONAL PROPERTY
IRA'S. KEOUGHS & OTHER QUAliFIED PLANS
OTHER ASSETS
TOTAL ASSETS $ $ $ $
LIABILITIES & NET WORTH SOLELY LIABLE JOINTLY LIABLE TOTAL
INDIVIDUAL 1 INDIVIDUAL 2
NOTES PAYABLE TO BANKS - SECURED SCHEDULE 6
NOTES PAYABLE TO BANKS UNSECURED SCHEDULE 6
NOTES PAYABLE TO OTHERS SECURED SCHEDULE 6
NOTES PAYABLE TO OTHERS UNSECURED SCHEDULE 6
MARGIN ACCOUNTS
ACCOUNTS PAYABLE lNCLUDE CREDlT CARDS
REAL ESTATE MORTGAGES PAYABLE SCHEDULE 5
TAXES PAYABLE
LOANS ON LIFE INSURANCE POLiCIES SCHEDULE 4
OTHER LIABILITIES
TOTAL LIABILITIES $ $ $ $
NET WORTH $ $ $ $
CONTINGENT LIABILITIES INDIVIDUAL 1 INDIVIDUAL 2 JOINT TOTAL
AS GUARANTOR OR ENDORSER
ON LEASES OR CONTRACTS
FOR LEGAL CLAIMS OR JUDGMENTS
TAX CLAIMS OR DISPUTES
LETTERS OF CREDIT
FUTURE CAPITAL CONTRIBUTIONS
OTHER
TOTAL CONTINGENT LIABILITIES $ $ $ $

Note: CONTINGENT LIABILITIES SCHEDULE MUST BE COMPLETED. IF NONE, THEN WRITE “NONE” ON THE SCHEDULE.

SOURCES OF CASH INCOME MONTHLY EXPENDITURES
FOR THE YEAR ENDED: INDIVIDUAL 1 INDIVIDUAL 2 INDIVIDUAL 1 INDIVIDUAL 2
WAGES AND SALARIES $ MORTGAGE/RENT – RESIDENCE(S) $ $
BONUSES. COMMISSIONS. ETC. ALL OTHER DEBT SERVICE
INTEREST & DMDENDS STATE & FEDERAL INCOME TAXES
RENTAL INCOME /NET OF EXPENSE} INSURANCE
PARTNERSHIP DRAWS. DISTRIBUTIONS ALIMONY
OTHER OTHER
TOTAL CASH INCOME $ $ TOTAL MONTHLY EXPENSE $ $

NOTE: IF A SOURCE OF INCOME OR A MONTHLY EXPENDITURE IS JOINT, PLACE A “v” IN THE APPROPRIATE BOX. ALIMONY, CHILD SUPPORT OR SEPARATE MAINTENANCE INCOME NEED NOT BE REVEALED IF YOU DO NOT WISH TO HAVE IT CONSIDERED AS A BASE FOR OBTAINING CREDIT.

NUMBER OF DEPENDENTS: AGES OF DEPENDENTS: HAVE YOU DRAWN A WILL? EXECUTOR/TRIX:
ARE YOU A DEFENDANT IN ANY SUITS OR LEGAl ACTIONS? HAVE YOU EVER FILED A PETITION IN BANKRUPTCY OR HAS ONE BEEN FILED
IF YES, DESCRIBE: INDIFIDUALLY AGAINST YOU?
  ARE YOU AN EXECUTIVE OFFICER, DIRECTOR, OR PRINCIPAL SHAREHOLDER OF A BANK?
  BANK:

IF THE SPACE PROVIDED IS NOT SUFFICIENT. ADDITIONAL SCHEDULES MAY BE ATTACHED. TO INDICATE OWNERSHIP IN THESE SCHEDULES, CIRCLE " 2 OR J IN THE APPROPRJA TE SPACE TO INDICATE INDMDUAL 1, INDIVIDUAL 2, OR JOINT RESPECTIVELY.

SCHEDULE 1 - CASH

NAME AND LOCATION OF INSTITUTION ACCOUNT TYPE & NUMBER BALANCE OWNED BY PLEDGED?
$

SCHEDULE 2- GOVERNMENT AND READILY MARKETABLE SECURITIES

FACE VALUE OF SHARES OWNED BY DESCRIPTION COST CURRENT MARKET VALUE AMOUNT PLEDGED
$ $ $

SCHEDULE 3 - NON-MARKET ABLE SECURITIES

# SHARES OWNED % OF TOTAL SHARES OWNED BY DESCRIPTION VALUE ($) AMOUNT PLEDGED ($)

SCHEDULE 4 - LIFE INSURANCE

INSURANCE COMPANY OWNED BY BENEFICIARY FACE VALUE CASH VALUE POLICY LOANS AMOUNT PLEDGED
$ $ $ $

SCHEDULE 5 – REAL ESTATE (IF PARTIALLY OWNED, GIVVE TOTAL PROPERTY INFORMATION, NOT YOUR SHARE)

DESCRIPTION & LOCATION OWNED DATE ACQUIRED COST VALUE MORTGAGE BALANCE MONTHLY PAYMENT NET YEARLY CASH FLOW*
BY %
$ $ $ $

*DEFINED AS TOTAL cASH INCOME LESS DEBT SERVICE_tAXES AND OTHER CASH EXPENSES.

SCHEDULE 6 – NOTES PAYABLE (EXCLUDE DEBT REPORTED IN SCHEDULE 5)

NAME AND ADDRESS OF NOTE HOLDER OBLIGOR TYPE OF LOAN CURRENT BALANCE ($) MONTHLY PAYMENT ($) COLLATERAL

THE INFORMA TION SET FORTH ABOVE IS TRUE AND CORRECT AND IS PROVIDED TO Gateway Bank FOR THE PURPOSE OF OBTAINING OR MAINTAINING CREDIT OR OTHER FINANCIAL ACCOMODATIONS. THE BANK IS AUTHORIZED TO CONFIRM ANY OF THE INFORM A TlON SET FORTH ABOVE, AND ANY PERSON HA VING KNOWLEDGE REGARDING SUCH INFORMA TlON IS HEREBY AUTHOR/ZED TO DISCLOSE THAT INFORMATION TO THE BANK I HEREBY AUTHOR/ZE THE BANK FROM TIME TO TIME TO OBTAIN CREDIT REPORTS ON ME, TO FURNISH INFORM A TION REGARDING ITS CREDIT EXPERIENCE WITH ME TO CREDIT REPORTING AGENCIES AND OTHER PERSONS, AND TO PROVIDE COPIES OF THIS FINANCIAL STATEMENT TO ITS AFFILIATES.

SIGNATURE AND DATE SIGNATURE AND DATE (OTHER PARTY IF JOINT)

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